<!--
  ========================LICENSE_START=================================
  screenit-web
  %%
  Copyright (C) 2012 - 2020 Facilitaire Samenwerking Bevolkingsonderzoek
  %%
  This program is free software: you can redistribute it and/or modify
  it under the terms of the GNU Affero General Public License as published by
  the Free Software Foundation, either version 3 of the License, or
  (at your option) any later version.
  
  This program is distributed in the hope that it will be useful,
  but WITHOUT ANY WARRANTY; without even the implied warranty of
  MERCHANTABILITY or FITNESS FOR A PARTICULAR PURPOSE.  See the
  GNU General Public License for more details.
  
  You should have received a copy of the GNU Affero General Public License
  along with this program.  If not, see <http://www.gnu.org/licenses/>.
  =========================LICENSE_END==================================
  -->
<html xmlns:wicket="http://wicket.apache.org">
<wicket:extend>
    <h1 class="pageTitle">
        <wicket:message key="titel"/>
    </h1>
    <div class="row-fluid form-horizontal">
        <div wicket:id="huisartsOpvraagPanel"></div>
    </div>

    <div wicket:id="uitstrijkendHuisartsContainer">
        <fieldset>
            <div class="row-fluid form-horizontal">
                <div wicket:id="paspoort"></div>
            </div>
            <div class="row-fluid form-horizontal">
                <form wicket:id="form">
                    <fieldset>
                        <div class="span12">
                            <div class="span5">
                                <div class="control-group">
                                    <label class="control-label">Aantal formulieren</label>
                                    <div class="controls">
                                        <input type="text" wicket:id="aantal"/>
                                    </div>
                                </div>
                            </div>
                            <div class="span5">
                                <div class="control-group">
                                    <label class="control-label">Locatie</label>
                                    <div class="controls">
                                        <select wicket:id="huisartsLocatie"></select>
                                    </div>
                                </div>
                            </div>
                            <div class="span2">
                                <div class="control-group">
                                    <div class="form-actions clearfix">
                                        <button class="btn btn-success right" wicket:id="aanvragen">Aanvraag</button>
                                    </div>
                                </div>
                            </div>
                        </div>
                    </fieldset>
                </form>
            </div>
            <div class="row-fluid" wicket:id="aanvraagContainer">
                <div wicket:id="aanvraagDataTable"></div>
            </div>
        </fieldset>
    </div>
</wicket:extend>
</html>
